exploring the history of pregnancy, birth, and infant care

What is the Obstetrical Dilemma? |Squished Pt 1|

In western culture, there is a long tradition of women suffering through labor–something about an apple? Throughout the history of obstetrics, theories have been tossed about to explain humanity’s seemingly unique difficulties in childbirth. One of the more recent theories is the Obstetrical Dilemma which posits that there is a tug of war between the female pelvis being narrow enough for bipedalism and gestation length with regards to fetal head size, thus human females are less efficient at bipedalism than men, they give birth to premature babies relative to other species, and they need a lot of specialized medical help to give birth safely. But what if it’s all nonsense?

Origins of the Obstetrical Dilemma

The OD hypothesis came into being around the same time that hospital birth was becoming the norm in the United States. In 1949, Aldoph H. Schultz, from the John Hopkins University School of Medicine in Baltimore, Maryland published a paper titled Sex Differences in the Pelves of Primates about the pelvic measurements of a variety male and female cadavers from a selection of primate species. (This is a good time for you to put down your beverage, swallow your food, etc to avoid spit-taking or choking.) Among these non-human primate species are chimpanzees, gorillas, and negroes.

It gets worse.

Schultz believed that black people represented a different species of primate, describing their pelvic measurements as more animalistic than whites, as a means of explaining why they had easier births. His research was used to justify the lack of medical care available to pregnant black women across the U.S. but even more so in the Jim Crow south.

There are many reasons (beyond pelvic width and fetal size) that a woman may want or need access to a hospital before, during, or after birth– and black women had few or no options at the time. And I don’t want to hear the “product of his time” nonsense, this was a concern at the time: an article published the same year as Schultz’s showed that less than 10% of babies born to black mothers took place at a hospital in Mississippi (Dent, 1949) where hospitals were segregated into the 1960’s. And to this day, women of color in the United States are less likely to have access to prenatal care and face a higher likelihood of dying giving birth.

This blatantly racist and (wholly inaccurate) research is the kind of thing the majority of academics would like to see consigned to history but because attitudes about women’s ability to give birth haven’t changed since the 1940’s, Schultz’s paper is still championed:

“The Obstetrical Dilemma hypothesis denotes the evolutionary trade-off(s) between neonate body and brain size, developmental state in terms of altriciality, and maternal pelvic size and shape constraints. As demonstrated by A.H. Schultz […] Schultz’s pioneering research inspired a suite of studies analyzing how neonatal-maternal dimensions and obstetric constraints are related to body size, sexual dimorphism, locomotion, litter size, and life history parameters.” -Ponce de Leon and Zollikofer, 2016.

Man the Hunter

But it wasn’t until Washburn’s 1960 “Tools and Human Evolution” article in Scientific American that the Obstetrical Dilemma was punted into popular consciousness and he is often credited as the first scientist to publish on the subject of the OD. Washburn was a contemporary of Schultz, and his work is cited frequently by Schultz.

The Scientific American article is generally about how tool use by pre-human ancestors shaped modern human physiology– which is certainly a concept I support– however, the article was very much of its time. For example, he describes a “man-ape” similar to modern gorillas and even monkeys as a kind of “missing link” between modern humans and other primates. (In case you read the original: today we understand that there is no “missing link”, no “ascent of man” nor any “man the hunter”.)

Towards the end of Washburn’s Scientific American article he touches briefly on Obstetrical Dilemma as a justification for the patriarchy, or the cultural norms of his time, that is, a nuclear family unit with the wife as a financially dependent homemaker caring her husband’s children and property, while he leaves the home to go to work.

“The slow-moving mother, carrying the baby, could not hunt, and the combination of the woman’s obligation to care for slow-developing babies and the man’s occupation of hunting imposed a fundamental pattern of the social organization of the human species.” Washburn, 1960, 74.

Long Discredited but Still Popular

Though Obstetrical Dilemma was discredited as early as 1973, the foundations of the theory, the racism, the thinly veiled misogyny, and the disdain for the physical dependency of infants has remained (or grown) in western culture and has been spread around the world in the succeeding decades. Obstetrical Dilemma hypothesis has been used to justify both the lack of access to health care (for women of color and/or indigenous women), unnecessary and often dangerous interventions during birth, and to make women afraid of their supposedly flawed bodies.

“Human beings should not exist. Our skulls are so large that we risk being stuck and dying even as we are struggling to be born. Helped out by a technical team– obstetricians, midwife, and a battery of bleeping machines– the unwieldy cranium is followed into the light by a pathetic excuse for a mammalian body, screaming, hairless, and so muscularly feeble that it has no chance of supporting its head properly for months.” Taylor, The Artifical Ape, 4.

Grave Consequences

The logic goes that if a woman’s pelvis is the problem during birth, just by-pass it with a surgical birth. The resulting rise in c-section rates has led to a rise in maternal mortality. Obstetrical Dilemma isn’t just scientifically inaccurate– it’s killing women— healthy women are three times as likely to die from c-section than vaginal birth (Mascarelle, 2017). While c-sections can be life-saving for both mother and baby beyond fetopelvic proportions, they are contraindicated for “big babies” based on ultrasound estimates of fetal size, which has “significant error levels” (Milner, 2018) and have put millions at risk for surgical complications and risks in future pregnancies. The WHO recommends a c-section rate of 10-15%, stating that there is no evidence of a reduction in maternal or infant death beyond 10%. Yet in the United States, the average rate (from hospitals that report their stats) is 31.9% according to the the CDC.

Beyond Birth

The Obstetrical Dilemma has an impact on the lives of parents far beyond surviving birth, it colors cultural perceptions of women and infants by insisting that something is terribly wrong with newborns’ helplessness and the fault of the maternal body.

While Taylor’s imagining our earliest human ancestors laboring somewhere in the African savannah with a technical team and bleeping machines, real women to this day are giving birth in all kind of environments, very often at home. Many or most are doing so without an obstetrician, to newborns with extraordinary abilities, including lifting their heads, supporting their body weight with hand grip, crawling to the breast, holding the gaze of nearby humans, recognizing the language of their mothers, exhibiting a stepping reflex, and more. Pathetic indeed. As far as I am concerned, there is nothing wrong with the development of healthy newborns or with the material bodies that grow and give birth to them.

Take Home

Scientists like Schultz and Washburn were products of their time when racism and sexism– the foundations of the Obstetrical Dilemma– were considered scientifically valid. But in the face of forty-five years of data refuting the OD hypothesis, how can modern researchers, those who reject racism or consider themselves feminists, and base their work on the scientific method, perpetuate the Obstetrical Dilemma? This is a medical myth that justifies the unnecessary cutting of women’s bodies, via episiotomy or cesarean and has increased women’s suffering and maternal mortality for generations.

The OD needs to hurry up and die and be consigned to the grave yard of history along side the likes of eugenics.

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Dent, Albert W. 1949. “Hospital Services and Facilities Available to Negroes in the United States.” The Journal of Negro Education: The Health Status and Health Education of Negroes in the United States 18:3, 326-332